PROCALCITONIN: A NOVEL BLOODS MARKER IN CORONARY ARTERY DISEASE

Indian Journal of Fundamental and Applied Life Sciences ISSN: 2231– 6345 (Online)
An Open Access, Online International Journal Available at www.cibtech.org/sp.ed/jls/2015/01/jls.htm
2015 Vol.5 (S1), pp. 2887-2893/Rahmani et al.
Research Article
     PROCALCITONIN: A NOVEL BLOODS MARKER IN CORONARY
                       ARTERY DISEASE
      Farzad Rahmani1, *Mohammad Latif Rastian2, Abdolhakim Ghanbarzehi1, Mohammad
                       Behnammoghadam3, Abdolghani Abdollahimohammad4
      1
        Department of Medical Sciences, Iranshahr University of Medical Sciences, Iranshahr, Iran
      2
        Department of Medical- Surgical Nursing, Yasuj University of Medical Sciences, Yasuj, Iran
            3
              Department of Anesthesiology, Yasuj University of Medical Sciences, Yasuj, Iran
           4
             Nursing and Midwifery School, Zabol University of Medical Sciences, Zabol, Iran
                                      *
                                        Author for Correspondence

ABSTRACT
Introduction: Acute myocardial infarction (AMI) is the most common cause of death in the world.
Conventional biomarkers of CK-MB, myoglobin and troponin I (TnI) don’t have high confidence
compared with the gold standard (angiography). This has led to improved decision-making process in this
type of novel biomarkers of cardiac patients as Procalcitonin (PCT) used. Purpose: The aim of this study
was to determine the levels of PCT in AMI and to investigate their possible correlation with the release of
TnI, myoglobin and CK-MB. Materials and Methods: This study has been done on 135 patients suffering
from coronary artery disease patients in three groups including: STEMI, N-STEMI and U/A tests. After
obtaining blood serum samples from separate patients, biomarkers of PCT, myoglobin, CK-MB and TnI
was measured. Quantitative values for each biomarker were measured by chemiluminescence method.
Data analysis was performed using SPSS software, ANOVA and chi2 tests. Findings: PCT was elevated
in all groups of patients. It was detected in serum approximately 2- 3 h after the onset of the symptoms of
AMI. Variables of age, gender, family history of diabetes and a significant difference was found between
the three groups. Generally, difference of PCT with above biomarkers at entry and four hours, except for
patients with STEMI group was significant. Discussion & Conclusion: Considering the significant
differences between PCT with mentioned biomarkers, it could be considered as a novel marker for
diagnosis of AMI.

Keywords: Procalcitonin, CK-MB, Troponin I, Acute Myocardial Infarction

INTRODUCTION
Diagnosis of Acute coronary syndrome (ACS) is based on an assessment of risk factors, careful and rapid
assessment of ECG, and measurement of cardiac enzymes. Cardiac troponins, creatinine kinase
isoenzyme MB (CK-MB) and myoglobin, which are routinely used in the diagnosis of ACS, are not
elevated in the initial hours, removing their value in an early diagnosis (Anthony et al., 2008).
This has caused a kind of perplexity in diagnosis of acute heart stroke in some patients suffering from
acute coronary syndrome. Therefore some patients are not diagnosed and are deprived of treatments. To
improve decision- making process in patients suffering from acute coronary syndrome and myocardial
infarction and to reduce the length of hospitalization, a lot of interest has appeared to use novel cardiac
biomarkers such as PCT which is one of the fast methods of measurement if laboratory and bedside
(Bektas et al., 2011).
Various markers are suggested to diagnose patients suffering from acute cardiac problems. Nowadays
despite these improvements because of normality of cardiac markers tests having obvious diagnosis value,
many patients suffering from acute ischemic are ignored which won’t have a favorable consequence for
them. Therefore everyday novel diagnosis markers are suggested for these patients (Bektas et al., 2011).
PCT (calcitonin precursor) is a new inflammatory marker with a protein structure which is helpful in early
detection of inflammation causes in acute phases. Also worldwide studies are done about the relation
between inflammatory diseases and PCT, among which some studies confirm the effect of this marker at
the time of acute inflammation (Reinhart et al., 2011; Tang et al., 2009; Nobre et al., 2008).

© Copyright 2014 | Centre for Info Bio Technology (CIBTech)                                           2887

Indian Journal of Fundamental and Applied Life Sciences ISSN: 2231– 6345 (Online)
An Open Access, Online International Journal Available at www.cibtech.org/sp.ed/jls/2015/01/jls.htm
2015 Vol.5 (S1), pp. 2887-2893/Rahmani et al.
Research Article
On the other hand in recent years PCT is proposed as special inflammation marker for bacterial
infections. But the number of conducted studies about predicting amounts of this marker in patients
suffering from non-infectious inflammation disease such as myocardial acute infarction is limited
(Sinning et al., 2011).
Practically limited studies are done in the field of heart diseases diagnosis and the relation between PCT
serum levels with sickness intensity. In the mentioned studies the diagnostic, prognostic and treatment
continuation of patients suffering from acute heart diseases such as MI, ACS and so on, are investigated
which were not confirmed definitively.
Troponins also are new indicators which are useful not only in myocardial necrosis diagnosis but in
classification of catching risk in different patients. Troponins are made from protein compounds of
contractile units of muscles; and their role is to provide calcium-binding compounds in collection of
troponin, tropomyosin, actin and myosin (Gilber et al., 2003). Clinical studies have shown that myoglobin
and TnI accompanied with isoenzyme CK-MB escalates after a heart stroke, and after a number of days
comes back to the base (Strunz et al., 2011). But a little escalation in the amount of TnI can be observed
for 7 to 10 days. It seems that the primary increase of TnI is cytosolic and later increase is related to the
release of TnI from myofibrils which are recovering in the heart. Also long term increase of troponin can
be observed in some of the patients suffering from pectoral angina. Although most of studies indicate TnI
increase in patients with heart disease, but the increase has also been observed in diseases other than heart
problems. TnI increases in patients suffering from chronic obstructive pulmonary and is used in prognosis
of hospitalized patients in intensive care units of chronic obstructive pulmonary acute attack (Jaffe et al.,
1996; Rosalki et al., 2004). Of course at the present time CK-MB isoenzyme is still used as the best
biochemical indicator in heart stroke diagnosis. The amount of CK-MB in myocardial constitutes 10 to 30
percent of total amount of creatine kinase. Because this isoenzyme is not considerably thick in tissues out
of heart, it is considered a relatively specific cardiac index. It should also be mentioned that CK-MB
sometimes increases in situations other than heart stroke (Apple, 1997; Baillard et al., 2003; Martins et
al., 2009).
 In the present study it is aimed to (i) measure changes of PCT serum levels (of first and fourth hours) in
identifying different states of patients with ACS(ii) compare the diagnostic performance of PCT to that of
serially measured myoglobin, CK-MB and cardiac TnI (cTnI) and to determine the relation between these
changes (Sinning et al., 2011; Bektas et al., 2011; Ataoğlu et al., 2010; Kelly et al., 2010; Kafkas et al.,
2008).

MATERIALS AND METHODS
Methodology
This prospective study was conducted in 135 patients admitted with a chief complaint of chest
pain to our emergency department. The patients were checked by cardiologist and because of suffering
from acute coronary syndrome were sent to pathobiology laboratory for some medical tests. In this
research patients are classified into three groups of STEMI, N-STEMI and U/A that their disease is
diagnosed by emergency specialist based on clinical and paraclinical results. Definition of acute coronary
syndrome Patients with ACS were classified into the following:
1. STEMI: defined as having ST-segment elevation ≥1 mm in two contiguous leads (or ≥2 mm in
V1 to V3 leads) or new left bundle branch block together with chest pain for > 30 min and/or evidence of
myonecrosis.
2. NSTEMI: defined as no ST-segment elevation on ECG despite chest pain for more than 30 min.
3. UA: defined as ischemic chest pain lasting more than 30 min with no evidence of myonecrosis or ST
elevation (Sebnem et al., 2011).
Patients with a malignant tumor, liver disorders and renal disorders, chronic rheumatoid arthritis, brain
ischemia, acute mesenteric ischemia and pregnant women were excluded from the study.
When patients were satisfied and testimonial was signed and questionnaire was completed, 5 milliliter of
blood sample was taken from fasting patients. Later their blood serum was separated to measure TnI,

© Copyright 2014 | Centre for Info Bio Technology (CIBTech)                                            2888

Indian Journal of Fundamental and Applied Life Sciences ISSN: 2231– 6345 (Online)
An Open Access, Online International Journal Available at www.cibtech.org/sp.ed/jls/2015/01/jls.htm
2015 Vol.5 (S1), pp. 2887-2893/Rahmani et al.
Research Article
Myoglobin, PCT and CK-MB and maintained in 70 degrees centigrade. Levels of conventional cardiac
markers, namely CK-MB, TnI and myoglobin, were measured by in vitro quantitative electro
chemiluminescence immunoassay (ECLIA), sandwich test-specific antibody system and myoglobin
STAT (Short TurnAround Time) kits. TnI measurement was done by TnI kit made in Dia Sorin Company
of Italy (REF 315.101) (Schneider et al., 2007; Sebnem et al., 2011).
PCT was measured by quantitative method of luminescence and using PCT LIAISON kit made in
B.R.A.H.M.S company of Germany (REF 318.101) (Schneider et al., 2007; Eisenhut, 2010).
CK-MB measurement was done by quantitative method of luminescence and using Liaison CK-MB kit
(Eisenhut, 2010).
Statistical Analysis
Data analysis was done using SPSS software and ANOVA tests and Chi 2; and P

Indian Journal of Fundamental and Applied Life Sciences ISSN: 2231– 6345 (Online)
An Open Access, Online International Journal Available at www.cibtech.org/sp.ed/jls/2015/01/jls.htm
2015 Vol.5 (S1), pp. 2887-2893/Rahmani et al.
Research Article
The mean Cardiac TnI levels in arrival STEMI (6.84±2.04), NSTEMI (8.05±2.56), and UA patients
(0.71±0.03) were significantly higher than healthy volunteers (0.2±0.04) (Table 2).The mean CK-MB
levels in arrival STEMI (13.82±2.07), NSTEMI (10.22±1.6) were significantly higher than healthy
volunteers (3.03±1.34) and UA patients (3.46±0.38) (Table2). The mean serum myoglobin levels in
arrival STEMI (191.11±34.57), NSTEMI (174.2±27.29) were significantly higher than healthy volunteers
(37.1±10.9) and UA patients (30.28±4.51) (Table2). The mean serum PCT levels in arrival STEMI (1.65 ±
0.53), NSTEMI (1.95±0.62), and UA patients (0.65±0.05) were significantly higher than healthy
volunteers (0.05±0.01) (Table2). The mean CK-MB levels in fourth hour STEMI (91.67±8.51), NSTEMI
(36.02±3.29), and UA patients (4.45±0.56) were significantly higher than healthy volunteers (3.03±1.34)
(Table2). The mean Cardiac TnI levels in fourth hour STEMI (8.12±3.81), NSTEMI (9.38 ±2.09), and
UA patients (1.19±0.04) were significantly higher than healthy volunteers (0.2±0.04) (Table 2). The mean
serum myoglobin levels in fourth hour STEMI (316.09±53.22), NSTEMI (239.74±41.27) were
significantly higher than healthy volunteers (37.1±10.9) and UA patients (35.72±6.54) (Table2). The
mean serum PCT levels in fourth hour STEMI (4.61±1.04), NSTEMI (4.81±1.45), and UA patients
(1.01±0.92) were significantly higher than healthy volunteers (0.05±0.01) (Table 2).

Table 3: Relation of Arrival PCT of Patients with Arrival and Fourth hour TnI, Myoglobin and
CK-MB
Patients Group                                         P Value of PCT:
                                                       CK-MB         Troponin I Myoglobin
U/A group(Arrival)                                     0.00          0.00        0.00
U/A group (Fourth hour)                                0.00          0.00        0.00
N-STEMI group(Arrival)                                 0.00          0.00        0.00
N-STEMI group (Fourth hour)                            0.00          0.00        0.00
STEMI group(Arrival)                                   0.172         0.03        0.201
STEMI group(Fourth hour)                               0.693         0.07        0.801

There was a significant difference between arrival PCT in U/A group with STEMI and N-STEMI groups
(P =0.00). This means that PCT amount in U/A group was less than STEMI and N-STEMI groups but this
difference between two groups of STEMI and N-STEMI was not significant (Table 3). PCT amount of
fourth hour in U/A group had significant difference with STEMI and N-STEMI groups (P=0.00). This
means that PCT amount in U/A group was less than STEMI and N-STEMI groups. But this difference
between STEMI and N-STEMI groups was not significant (Table 3). Amount of arrival TnI in U/A group
was significantly different with STEMI and N-STEMI groups (P=0.00). But the difference between two
groups of STEMI and N-STEMI was not significant (Table 3). Amount of fourth hour TnI in U/A group
was significantly different with STEMI and N-STEMI groups (P=0.00), but the difference between two
groups of STEMI and N-STEMI was not significant (Table 3). Amount of arrival PCT had significant
relation with arrival TnI (P=0.00) and also with arrival CK-MB (P=0.00) and myoglobin (P=0.00). In
each group the results were as following: the relation between patients of N-STEMI groups for arrival
PCT with TnI, myoglobin and CK-MB was significant but this difference was not significant for patients
of STEMI group (Table 3). In every heart disease the results were as following: among patients of U/A
group and N-STEMI the fourth hour PCT relation with fourth hour TnI, myoglobin and CK-MB was
significant. In STEMI group fourth hour PCT relation was significant with TnI but insignificant with CK-
MB and myoglobin (Table 3).
Discussion
Nowadays biomarkers are used in early diagnosis of many diseases and by novel technologies the
markers sensitivity to diagnose diseases gets more (Eisenhut, 2010; Sentürk et al., 2007). In recent years
PCT biomarker due to its low level of plasma in healthy people (0.5ng/ml) and its increase in less than
three hours, is used in any inflammatory diseases (Sponholz et al., 2006; Brunkhorst et al., 1999;
Picariello et al., 2011; Moya et al., 1975).

© Copyright 2014 | Centre for Info Bio Technology (CIBTech)                                           2890

Indian Journal of Fundamental and Applied Life Sciences ISSN: 2231– 6345 (Online)
An Open Access, Online International Journal Available at www.cibtech.org/sp.ed/jls/2015/01/jls.htm
2015 Vol.5 (S1), pp. 2887-2893/Rahmani et al.
Research Article
On the other hand despite CK-MB, Myoglobin and TnI diagnosis markers’ high diagnosis value in ACS,
false positive cases of these tests increases waste of cost and doing intermediary diagnostic measures. In
fact the belief that CK-MB and TnI only release in myocardial cell’s irreversible damage is being
reviewed (Rosalki et al., 2004; Apple, 1998, Baillard et al., 2003; Martins et al., 2009). In a study on
marathon runners PCT level significantly increased.
PCT has also increased in patients suffering from sepsis, malignant blood pressure, pulmonary embolism
and kidney failure. According to researchers’ idea stress in heart cells increases cardiac myocytes’
penetration and is different from irreversible damage arising from cell death (Moya, 1975; Assicot, 1993;
Maruna, 2000; Müller, 2001; Dandona, 1994; Meisner, 1998; Abbasi et al., 2010; Kruif, 2010).
To confirm the diagnosis efficiency of a heart test and compare it with other methods there is a need to
confirm it with a golden standard method.
Diagnosis golden standard in ACS is angiography and the level of PCT marker’s sensitivity and diagnosis
in detecting ACS must be confirmed by this method.
Based on this in the conducted study results show a relation between increase or decrease of markers and
its importance exists in this relation, and based on this results are collected and analyzed.
Variables of age, sex, diabetes, Total Cholesterol, Triglycerides and family history of CAD was
significantly different among three groups of heart patients; and in variables of Triglycerides there wasn’t
a significance difference among the groups. According to the results obtained from research this case is
noteworthy. Prestige bias or prevarication bias can be effective in the results of these variables.
There is significant difference between arrivals PCT of the three groups, but the difference between two
groups of STEMI and N-STEMI was not significant. Also fourth hour PCT level in the three groups was
significantly different, but the difference between two groups of STEMI and N-STEMI was not
significant. There was a significant difference in three groups about amount of arrival TnI but the
difference between two groups of STEMI and N-STEMI was not significant. Also the fourth hour TnI
level was significantly different among three groups but the difference between two groups of STEMI and
N-STEMI was not significant.
Generally arrival and fourth hour PCT was significantly different with arrival and fourth hour TnI,
Myoglobin and CK-MB except among patients of group STEMI.
Conclusion
PCT is proposed as a diagnosis biomarker in acute inflammatory phase. Studies done about the use of this
marker in ACS diagnosis which is an inflammatory process improvably indicate its usability; but some
other studies emphasize its inefficiency in diagnosis and see it only as a predictor of heart patients’
survival. In the present study the results show that there is significance relation between PCT level
changes with TnI, Myglobin and CK-MB as a new marker in ACS diagnosis.

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An Open Access, Online International Journal Available at www.cibtech.org/sp.ed/jls/2015/01/jls.htm
2015 Vol.5 (S1), pp. 2887-2893/Rahmani et al.
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